upturned extremity of the fissure of Sylvius. The lesion is most likely cortical, for if deep in this locality there will be hemianæsthesia. It is probably limited to this area, because if it extends anteriorly there would be some motor impairment, or posteriorly, hemianopsia. From the patient's age and the manner of onset of his symptoms, it is most likely a cortical hemorrhage. With these data and this presumptive diagnosis, an exploratory trephining is advised. This was done on August 27th, 1896. After the usual preparation, the parietal boss was exposed on the left side and an inch and a quarter trephine opening was made immediately behind it, this having been somewhat enlarged, their being no brain pulsations present, the dura was incised. The brain presented an unhealthy appearance. A sub-cortical exploration with the trocar revealed a recent blood cyst, the walls and adjacent brain were softened. The cyst having been evacuated and its cavity cleansed, the dura was sutured and the wound completely closed. Recovery from the operation occurred without incident. An examination made at the time of final removal of the dressings showed some improvement in the patient's ability to understand printed letters-he could, with the alphabet card, distinguish correctly perhaps two out of three, and with difficulty and hesitation could spell out some words. He is otherwise as before the operation, excepting that an examination shows a right-sided hemianopsia, and fields taken by Dr. Jessup show an abrupt central termination. Word received quite recently from the patient announces slight further improvement in his ability to discern the meaning of letters. Case II.-Male, æt. forty-five; was seen August 2d, 1896, with the following history: Left-sided otorrhoea at intervals since infancy. Has had several attacks of acute pain, none, however, as severe as the present one. This attack came on while he was on a trip in the latter part of July, 1896. The pains began in the ear, extended to the head, and he came home almost delirious with their severity. There was tenderness all over the left side of the head. No mastoid swelling. He had fever and some delirium. Could not recall the names of those about him. At this time the knee-jerks were normal and there was no ankle clonus. Dr. Shallcross concurred in the opinion of the writers that the mastoid should be immediately opened. Having prepared the field of operation in the usual manner, an incision was made just posterior to the Pinna and the entire mastoid. exposed, after which the antrum was opened in the supra meatal triangle of MacEwen (this being a space bounded by the lower posterior root of the zygoma and the superior posterior edge of the ex ternal auditory canal), the bone was found unusually thick. On entering the cavity nothing, save a few bubbles of air escaped, and the opening of the mastoid proper was with negative result. Following the operation, the pain and delirium ceased, but the amnesic aphasia was very pronounced. He could not recall ordinary nouns, especially names of places and people. Did not know the name of a mileage book which was handed him, although he had used them for years. Calls a conductor a "passenger," and afterwards a "postal card." Thus showing a degree of paraphasia. The knee-jerks are now exaggerated, especially the right, and there is right-sided ankle clonus. In the course of a few days the pain returned. This was worse at night, and his headaches were especially severe on the right side of the head. He was very irritable, delirious, and threatened suicide. Early in the morning of August 11th he was trephined one and a quarter inch behind, and one and a half inch above the external auditory meatus, the indications being clearly that there was an abscess in the temporal lobe. On removal of the button of bone the brain protruded; the meninges were quite injected, and there was an entire absence of pulsation. The trephine opening was now enlarged upward and forward after which the dura was incised. On palpating the brain distinct fluctuation could be elicited. The cortex was incised, and this gave vent to a gush of thin foul-smelling pus some ounce and a half in quantity. On introducing the finger, a cavity, the size of a hen's egg, extending anteriorly and toward the median line with apparently a well-defined wall, could be made out. This was thoroughly irrigated with a boracic acid solution and then packed with sterile gauze wrung out of the same solution. The wound in the dura was for the greater part closed allowing merely sufficient opening at the most dependant portion to ensure good drainage. After a few days the gauze drain was replaced by a glass tube because the latter would better drain the pus which had changed to a rather thick creamy consistency. The cavity was also first cleansed with peroxide of hydrogen (full) strength), and afterwards irrigated with boracic acid solution. Healing progressed rapidly, the cavity gradually becoming obliterated from the bottom. A subsequent examination of the reflexes showed the knee-jerks to be free but less than before the operation. The ankle clonus was not now present. The degree of amnesia since the operation has varied some days he would be quite aphasic, and again the aphasia was only shown by an occasional lapse in conversation. The general tendency is towards improvement. Case III. Boy, æt. fourteen years, who was well until eight months of age, when he fell, striking the left side of his head against a range. This occurred at eight A. M.; he cried some, but was seemingly all right the rest of the day. In the evening he became drowsy, and went into convulsions which were entirely limited to the left side. These continued for several hours and were followed by coma. In the morning he was aroused, but was found to have a left-sided hemiplegia, and he could not make use of his left side for a month. During the first week following the convulsions he would frequently have symptoms as of impending convulsions but they did not supervene. After this, at intervals of from two to six months, he would have convulsions similar to the first one, always with a subsequent paresis of the left side. These of late have been more frequent and quite severe. They are of some minutes duration, but of late have not been followed by such marked weakness of the left side. Does not bite his tongue. Sometimes there are abortive attacks in which his speech gets thick and saliva dribbles." He repeatedly masturbates during sleep, which is often restless, and the occasion of moaning and incoherent talking. It is learned that the convulsive twitchings always begin in the face before the arm or leg are affected; indeed of late the arm and leg are not involved so severely as heretofore, but the facial movements do not improve. Knee-jerks are free; no ankle clonus. The conclusion reached is, that there was a slow traumatic hemorrhage, most likely meningeal, in the Rolandic region, at the time of the injury in infancy. An exploratory trephining was advised. Now a word about trephining for focal or Jacksonian epilepsy. The results have been rather disappointing as might be inferred. A clot may have been absorbed and left simply cortical instability as evidence of its former presence. This will not be benefited by operation. Again, secondary degenerative changes may have descended through the fibres of the corona even to the spinal cord. We can usually distinguish this condition; there is no use in trephining in the hope of cure then. So that trephining in these cases is simply an explorative procedure, often a mere measure of diagnosis. In this case a trephine opening of one and a quarter inches was made over the lower Rolandic area of the right side and enlarged upwards. The dura was incised, and no evidence of any pathlogic change found. The wound was closed and an uninterrupted recovery followed. He has had no convulsion since the operation, and his health is very good. But there has not been sufficient lapse of time to make observations of any value. SOME OBSERVATIONS ON ACUTE PELVIC SUPPURA TION.* BY SHELDON LEAVITT, M.D. Professor of Surgical and Medical Diseases of Women Hahnemann Medical U NTIL recently, the treatment of acute pelvic suppuration has been (1) by the expectant plan, (2) by the use of the aspirator, (3) by abdominal section, and (4) by vaginal hysterectomy. There is no doubt that many lives have been saved by each of these methods; but then, many lives have undoubtedly been sacrificed through the adoption of too severe treatment, while, on the other hand, many more have been lost through inaction. Our chance of success with a major operation is greatly reduced by the existence of acute inflammatory and suppurative action. This is what has driven many operators to give the expectant plan undue prominence in the treatment of acute suppurative inflammation in the pelvis, they preferring to procrastinate, in hope that the pent-up pus will itself find an avenue of escape. There are others who advocate the advisability of "going-for" pus, whenever and wherever found; and I am glad to be enrolled among such. But we should choose, with much care, the best means and the safest route. The older surgery suggested the aspirator; but the results of probing with a steel needle for occult pus-pockets proved to be dangerous and unsatisfactory. Modern surgery at first said: "Open up the abdomen, break up adhesions, remove the appendages, clean up well, and drain, if necessary." This works to our liking in women who have retained sufficient vitality to withstand the shock; but among our patients there are many who are unable to bear the strain. Subsequently it was learned that vagino-salpingo-hysterectomy for such cases resulted in reduced mortality; and accordingly this has been a favorite. operation with many wide-awake surgeons; sufficient justification for removal of the uterus being found in its usual involvement in the pathological process, and its uselessness after removal of the appendages. But vaginal hysterectomy is often attended by symptoms of profound shock, which certain debilitated patients cannot withstand. I want it distinctly understood that I am not about to urge a substitute for either cœliotomy or vaginal hysterectomy, save in *Read before the American Institute of Homoeopathy at Detroit, June, 1896. those cases where the patient is really unable to bear surgical intervention of the more radical kind with good hope of a favorable issue. On the other hand, I do not hesitate to commend it as a substitute for aspiration, and for expectant treatment, inasmuch as I have lost what little faith I ever had in both these methods. What is claimed for the vaginal incision in the cases, is (1) its simplicity, (2) its freedom from shock, and (3) its prompt efficiency. It can be undertaken with good prospect of immediate, even if temporary relief. To be sure it will not always rescue the patient from either impending, or remote peril, as the life forces may already be in decay; but it certainly brightens the prospect in many otherwise hopeless cases. Without further comment I take pleasure in submitting reports of the following four desperate cases: Mrs. B————, 26 years of age, short, thin and rather anæmic, the mother of one child, three years of age, came to Hahnemann Hospital for the relief of pelvic pain, weight and pressure, considerably increased at the menstrual period. She was unable to do much work, and, withal, reckoned herself as quite an invalid. She gave a history of puerperal inflammation and suppuration which confined her to her bed for a number of weeks, the details of which could not be learned. Physical exploration revealed slight thickening behind and to the side of the uterus, which modified free uterine mobility. The uterus itself was slightly enlarged, and the cervical canal was in a catarrhal state. The rectum was also sensitive to vaginal touch, and showed considerable irritation of its mucous membrane. In the presence of a sub-class the patient was anesthetized, the uterus dilated and curetted and the sphincter-ani well stretched. For six days the pulse and temperature remained normal, and the case showed every sign of favorable progress, when suddenly the patient experienced a chill, followed by a rise in temperature and severe pain in the lower part of the abdomen, with some tympanites. During the succeeding ten days the temperature remained abnormally high, reaching on one or two occasions 104° F., and the pulse range was from 100 to 120. At the end of that period the uterus was entirely encased and immobalized as the result of the pelvic exudation. The general appearance of the woman was unfavorable, and the mental faculties were considerably dulled. In short, the case became exceedingly threatening. In view of the former suppurative history, as well as the present posture of the case, I decided to practice surgical intervention with a view to evacuation of the pus which was presumed to exist in the pelvic |